Provider Demographics
NPI:1518286541
Name:FULLER, ANDREW DIXON (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DIXON
Last Name:FULLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6228
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-6228
Mailing Address - Country:US
Mailing Address - Phone:903-735-9802
Mailing Address - Fax:903-735-9806
Practice Address - Street 1:4100 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2732
Practice Address - Country:US
Practice Address - Phone:903-735-9802
Practice Address - Fax:903-735-9806
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119199367500000X
ARR72921367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered